Appropriate Role for NPs

[siempre595]

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I was just wondering what most residents feels is the appropriate role for an NP on a service?
Our hospital has an NP on nearly every speciality team including in the ICUs. While some of them are awesome, very kind to the residents, share in the work, offer appropriate teaching etc, others have terrible attitudes toward us, no respect, steal procedures from us, and have actually "told on" some of my classmates stating they were "rude" to them because they stood up for themselves or for a patient against the NP's wish.
I just don't think it's okay for NPs to be pimping residents or stealing procedures, no matter their level of experience. I never thought that was the role of the NP. The teams which run the best with the NPs are the ones in which they have their own patients and do not seem to be "sharing" in the residents' patients. Just wondering how it works at other places and if there are any suggestions for how to deal with NPs taking procedures away from residents?

 

[JadinSleeper]

It is my opinion that they have no role whatsoever in the formal training or supervision of medical students, interns, or residents. If I had wanted to be trained by a nurse, I would have went to nursing school.

Likewise, if they want to educate physicians, then they are welcome to complete their pre-reqs, take the MCAT, apply and be accepted to medical school, complete a residency and possibly fellowship, secure an academic appointment, and then pimp the hell out of me.

I have had issues with young assertive NPs who think that their nursing theory classes and 1 years work experience in backwater ED somehow make them our clinical peers. I even fell for it as a medical student. And in many run-of-the-mill clinical scenarios, they are able to function adequately. But I have noticed they have a very profound inability to think outside of an algorithmic approach to complicated patients. Plus, they just don't know how much they don't know.

 

[bigDinLV]

Your residency program should have a emphsis on teaching residents. Thats why it is there right?? The NP or PA or whatever should be there to provide serivce.

I was at a surgery program where they used to use PA's for everything, then they started training residents. The PA's were then used to provide service, never bumping the residents in the OR.

Occasionally the PA's wanted in on cases and that is understandable. There was a little bit of distress on occasion.. They have to realize they are at a teaching program though, emphasis should be on teaching.

 

[DrMom]

I was recently on a service that used PAs/NPs along side residents. The PAs/NPs did a lot of the notewriting, dispo planning (setting up rehab and extended care), dictations, etc. Basically, they covered a lot of the scutwork and jumped in with other things as needed.

 

[Long Dong]

At my internship during my ED month I was presenting to the PA like she was my attending.

 

[deleted6669]

At my internship during my ED month I was presenting to the PA like she was my attending.

this is fairly common practice. I precept pgy1-3 fp residents when they rotate through my dept.
most of them are there to learn procedures and we do a lot more of them than the attendings so it only makes sense for us to be the ones to teach them.
one of my attendings(in his 50's) recently told me he hadn't done an abscess I+D since he was a resident. not the guy I would want doing mine....and as we always have a pa in the dept we do the vast majority ( >95%) of the suturing, ingrown toenails, fx and dislocation reduction, ent and ophtho procedures, etc while the docs concentrate on unstable pts with mi's/cva's/multisystem trauma/etc.
if the residents want to learn how to do a thoracotomy or cut down I'm not the go to guy for that....🙂
when we are really busy and they aren't they help us out a bit by seeing lower acuity pts and if the general acuity level and volume is high we help them out by seeing higher acuity pts.

 

[peerie]

Yesterday I called a new IM doc to make an appt for myself. She is booked until mid-March, but the receptionist recommended that I see the NP - and pay the exact same amount. I could see the nurse in a week or so.

When I said that I didn't want to see a nurse but wanted to see a doctor (for obvious reasons, ie a doctor is not a nurse), the receptionist said to me that the NP was exactly the same as the IM physician except for, like one year's difference in education.

Oh no I said! there is a HUGE difference and more like about 7 years heavy training in difference. The receptionist kept insisting that the NP was the 'equivalent' to the IM doc and I finally had to hang up, even though I put up a strong fight against her.

I think there is a place in the hierarchy for PAs and NPs, but to insist that a NP is the "equivalent" to a seasoned IM physician is outright wrong. We are creating a huge problem in medicine if we continue to encourage this thinking. I would have to believe that the IM office was somehow encouraging this thinking - or at least allowing it. Perhaps they weren't aware of what the receptionist was telling prospective patients. I will go and see another physician as a result.

 

[mig26x]

At my internship during my ED month I was presenting to the PA like she was my attending.

I would have drawn the line right there!!!

 

[peerie]

http://forums.studentdoctor.net/showthread.php?t=544538

Here is an interesting thread on the NP/PA etc forum. I didn't read the whole thing but it's interesting to see this thinking continued on their forum.

It seems to me that if you want to be the physician then you should go to medical school, and go through all the hard work and rigorous training it entails. If not, then be mindful of the position you do have.

 

[Long Dong]

I would have drawn the line right there!!!

Yeah I wasn't to happy about that ether, but the EM attending were to busy with the EM residents (calling consults) doing unstable patients, MI's, multisytem trauma. So the PA's would be like the attendings for the FPs and TYs doing like urgent care stuff. I was just a TY rotating threw for a month, didn't want to make a stink about it, on my way to the heaven that is derm.

 

[docB]

I would have drawn the line right there!!!

I'm curious what line you would have drawn and how you would have approached that with your clerkship or residency advisor.

 

[Faebinder]

I'm curious what line you would have drawn and how you would have approached that with your clerkship or residency advisor.

Probably the easiest thing is report a complaint to ACGME. (or he could be really evil and tell this to a site visitor for ACGME when the credentialing of the program comes around which usually happens every 3-4 years. This is not a healthy thing to do, but it's as last resort after all the channels have been exhausted.

 

[SLUser11]

I was just wondering what most residents feels is the appropriate role for an NP on a service?
Our hospital has an NP on nearly every speciality team including in the ICUs. While some of them are awesome, very kind to the residents, share in the work, offer appropriate teaching etc, others have terrible attitudes toward us, no respect, steal procedures from us, and have actually "told on" some of my classmates stating they were "rude" to them because they stood up for themselves or for a patient against the NP's wish.
I just don't think it's okay for NPs to be pimping residents or stealing procedures, no matter their level of experience. I never thought that was the role of the NP. The teams which run the best with the NPs are the ones in which they have their own patients and do not seem to be "sharing" in the residents' patients. Just wondering how it works at other places and if there are any suggestions for how to deal with NPs taking procedures away from residents?

MacGuyver, is that you?


No, nevermind....this thread lacks the tone of desperation and insecurity....

 

[deleted6669]

MacGuyver, is that you?


No, nevermind....this thread lacks the tone of desperation and insecurity....

NOPE, MIG26X is macgyver.....

 

[ssmallz]

I agree that NPs and PAs have absolutly no business doing the teaching of residents. If the attendings are too busy to teach they shouldn't have that many residents. During a Preop rotation, most of my supervision was by PAs however there was always an attending I could go to for the difficult cases. For most of the strait foward preops the PAs and NPs were fine but if a case was more difficult there was a significant difference between the attending's thought processes and the midlevel's.

Midlevels have not been through residency or medical and are not board certified in your particular specialty and therefore there is a ceiling on what they can teach you. In order to become the clinician that we all seek to be you need the level of expertise and insight that only an attending can give you.

This is in no way shape or form a knock on midlevels b/c it is not their job to be teaching us. They are excellent at the job they do but there is a significant difference between us and them. It is the jobs of the attendings and the residency director to enforce it.

 

[docB]

Probably the easiest thing is report a complaint to ACGME. (or he could be really evil and tell this to a site visitor for ACGME when the credentialing of the program comes around which usually happens every 3-4 years. This is not a healthy thing to do, but it's as last resort after all the channels have been exhausted.

Is it a violation of ACGME rules to have midlevels teaching?

I agree that NPs and PAs have absolutly no business doing the teaching of residents. If the attendings are too busy to teach they shouldn't have that many residents. During a Preop rotation, most of my supervision was by PAs however there was always an attending I could go to for the difficult cases. For most of the strait foward preops the PAs and NPs were fine but if a case was more difficult there was a significant difference between the attending's thought processes and the midlevel's.

Midlevels have not been through residency or medical and are not board certified in your particular specialty and therefore there is a ceiling on what they can teach you. In order to become the clinician that we all seek to be you need the level of expertise and insight that only an attending can give you.

This is in no way shape or form a knock on midlevels b/c it is not their job to be teaching us. They are excellent at the job they do but there is a significant difference between us and them. It is the jobs of the attendings and the residency director to enforce it.

I disagree that there is no role for midlevels in resident education. I think it depends on who it is and what they do. For stuff like basic suturing, wound care, splinting I think it's reasonable for midlevels to teach. In many places they do more of those skills than the docs. I know that when I was a resident I was taught splinting and casting by orthopedic cast techs, rape exams by a SANE nurse, fast tract stuff by midlevels and so on. I don't think that a lot of the cognitive and complicated stuff should be taught by midlevels because even though many are competent at them they do have a different process than the docs. But I think that saying there's no role for them in resident education or complaining, drawing lines, etc. as soon as you're told "And our PA here will be teaching you about..." is a poor use of perfectly good righteous indignation.

 

[Trifling Jester]

They should have no role whatsoever in resident education. I'd run, and run fast, from any program that had them teaching residents.

-The Trifling Jester

 

[NotAProgDirector]

Is it a violation of ACGME rules to have midlevels teaching?

No, but it's more confusing than that. Remember that the ACGME is actually an umbrella organization that covers each of the specialties. The overarching ACGME requirements mainly apply to institutions that want to host any residency program. Any rules about NP/PA's will be more explicitly dealt with by the separate RRC's for each field.

In IM, for example, it is perfectly acceptable, and in fact encouraged, to use NP/PA's to cover curricular topics under their scope of practice. However, the rotation and ultimately the backup for the resident needs to be an MD/DO. The MD/DO must be present, on site, and meet with the resident at least daily.

Rules for other fields will be different

I agree that NPs and PAs have absolutly no business doing the teaching of residents. If the attendings are too busy to teach they shouldn't have that many residents.

They should have no role whatsoever in resident education.

I disagree with these statements. As mentioned above, if the MD is really too busy to teach at all, then the IM RRC would consider that a violation -- but as long as they provide some backup and teaching, it's reasonable to use NP/PA's.

The key is how to use them. For example:

1. An anticoagulation clinic -- we have a specific nurse (not actually an NP) who runs our anticoag clinic. Mainly this is warfarin dosing. It's a great experience for residents for a very short period of time -- a few half days. Learning how to accurately dose warfarin is a key IM skill, and honestly the best way to learn it is from an RN who does it full time.

2. A woman's health clinic -- we have an NP who does only women's health -- mainly rountine PAP's, urinary incontinence, birth control, and menopause management. Again, this is an experience enriched with a specific population of patients, where the NP has years of experience and clearly knows what they are doing.

3. DocB mentioned other examples where non-MD/DO's could provide great teaching.

The bottom line is this: If the NP/PA/RN/other non-MD/DO has a specific clinical niche that they have developed expertise in, that the program leadership feels confident in their skills, that has some appropriate MD/DO ultimate backup, with clearly defined scope of practice -- it's often a very worthwhile experience.

Having a PA back up a resident in an ED doesn't fit that scenario, unless you're talking about a pre-triaged very low acuity walk-in type scenario, and even then it's a stretch.

...but the receptionist recommended that I see the NP - and pay the exact same amount.

This is going to be a huge driver of change in primary care. It's a bit ridiculous -- why should you (or an insurance company) pay the same for you to see an MD or a PA/NP? Patients already face financial choices -- go see your local "provider" (don't get me started about the ubiquity and acceptance of the medical community of this term) and pay $10 copay but wait a week, or go to the ED now for $50. $5 for simvastatin, but if you want Zocor it's $30.

It's only a matter of time before insurance companies figure this out, and decide to 1) drop reimbursement rates for midlevels and 2) drop co-pays for seeing midlevels. This will drive most patients to want to see a midlevel, since it's cheaper, and will change PCP's into midlevel managers. Whether or not this is a good thing remains to be seen.

 

[Taurus]

I can see the value of having NP/PA teach medical students and residents. If you do something full-time for years and years, most people get good at it and can teach others. For transients like medical student and rotating residents who spend a month on a non-specialty rotation, NP/PA's who are on the service are probably adequate to teach the most basic and routine cases, if the attendings are not available.

However, medicine as a profession needs to be careful in how it utilizes NP/PA's for teaching. It's not a far stretch to imagine that some of these NP/PA's may assume that they are equivalent to attendings. After all, they would be teaching residents, just like the attendings. Therefore, they must be equivalent. This is how the independence movement happened with NP's and CRNA's. Since they could handle the most basic and routine of cases independently or with little physician oversight, they erroneously thought that they could handle any case, even the most complex ones. Of course, they had no evidence to back up their claims but that didn't stop them. They lobbied lawmakers with these arguments and achieved autonomy.

If a service heavily uses NP/PA's to teach, then medical students and residents should talk to the program directors to have things changed.

 

[ESU_MD]

The vast majority of NP, DNPs PA's etc do not have dreams of "taking over" teaching residents etc... Once you actually work with these providers you will realize that.

what do you think a DNP is gonna do in a so-called independent practice? heart surgery>? come-on. they are gonna adjust coumadin, treat colds, play with insulin and give vaccines. not much to be jealous about.

These providers fill the void that you and I are unwilling to fill.

Let me ask the forum this- when you are in practice someday, who do you plan to have work in your office? and answer the first-line phone calls, or take out sutures, or call in refills, etc... a good NP is a very essential part of any practice, even if they want to wear a long white coat.

 

[mig26x]

NOPE, MIG26X is macgyver.....

nope! Im mig26x also known as mig24x two years before opening this account!! LOL.

 

[mig26x]

I'm curious what line you would have drawn and how you would have approached that with your clerkship or residency advisor.

In my residency program the only PA's that work directly with residents are the ED PA's and they have to discuss their cases with the ED attending, therefore presenting my case to an ED PA in my program will be the equivalent to presenting the case to another ED resident and you wouldn't do that when discussing/presenting patients, rigth?

 

[core0]

This is going to be a huge driver of change in primary care. It's a bit ridiculous -- why should you (or an insurance company) pay the same for you to see an MD or a PA/NP? Patients already face financial choices -- go see your local "provider" (don't get me started about the ubiquity and acceptance of the medical community of this term) and pay $10 copay but wait a week, or go to the ED now for $50. $5 for simvastatin, but if you want Zocor it's $30.

It's only a matter of time before insurance companies figure this out, and decide to 1) drop reimbursement rates for midlevels and 2) drop co-pays for seeing midlevels. This will drive most patients to want to see a midlevel, since it's cheaper, and will change PCP's into midlevel managers. Whether or not this is a good thing remains to be seen.

This is an interesting concept but really doesn't work under the current system. Most insurance companies don't credential NPPs so they have no way of seeing if they are billing for them. The only group that discounts NPPs is Medicare/Medicaid. With the adoption of the NPI the insurance companies could mandate billing under the NPI for NPPs but they haven't so far.

The other issue is that on the PA front (and probably on the NP front) the numbers in primary care have remained static even as the patient population has grown. PAs are going into specialty care at a much higher rate than ever. Since most NPPs are employed by the physician (groups) cutting reimbursement to NPPs will take one of the few areas a primary care physician can make a profit.

Until the US medical system moves away from a system based primarily on reimbursing for procedures and toward one that is based on outcomes and patient complexity the only thing that paying NPPs less does is to drive more of them out of primary care.

For what its worth I agree with you on the use of NPPs in a residency program. We don't usually have residents, but when we do, my job is to unload them to either get into the OR or keep their patient load to a manageable level so they actually learn something from the time here. If they want to learn a procedure I'm happy to show them. I also am happy to help them on what the attending considers important so they look good on rounds. One of our primary functions is to be the institutional memory on the service.

David Carpenter, PA-C

 

[peerie]

As a future family medicine doc (a FFMD for short, 🙂), I think our AAFP needs to get a stronger grip on this mid-level meltdown. Sticky note to self, how can I be involved in this in the future?

Anyway, I have learned alot from nurses and other auxilliary types. Often residents are too busy to talk to or teach students and so I have instead just tried to work directly with the people actually doing the procedures or whatever. They are awesome, and I have learned alot from them.

But! they have not been my supervisors. I think there is too much potential for backlash or subtle abusive dynamics if a PA or NP is 'in charge' of your education. When I have been on a service with a PA student, invariably they will try and outrank me or cut me down. There is definitely competition and hostility at times, which is unfortunate. Also, the PAs I sometimes work with in the ER fast-track have a very, very limited knowledge base and often are very poor at understanding what they are looking for when they order imaging studies or tests. It is very frustrating to see. I think it would be very upsetting to have them as my 'supervisor.'

Altho, Dave PA-C above - you sound like you would be a great person to work with! 👍

 

[docB]

I'm curious what line you would have drawn and how you would have approached that with your clerkship or residency advisor.

In my residency program the only PA's that work directly with residents are the ED PA's and they have to discuss their cases with the ED attending, therefore presenting my case to an ED PA in my program will be the equivalent to presenting the case to another ED resident and you wouldn't do that when discussing/presenting patients, rigth?

That's true but I don't really advocate residents presenting to PAs. I do think that PAs can teach residents about technical skills. That goes to the "no role in education" comments some had made in this thread.

My question to you though was about how you would "draw the line" at being taught by a midlevel. Would you not rank any program that has midlevels teaching? How about any program that uses midlevels on the off chance you might find yourself being taught by one at some point? If you found yourself in that position how would you address it with your PD? That might get sticky and you may need to decide just how much not being taught by a midlevel means compared to all the other good stuff a program may have to offer.

 

[Long Dong]

Having a PA back up a resident in an ED doesn't fit that scenario, unless you're talking about a pre-triaged very low acuity walk-in type scenario, and even then it's a stretch.

The patients were already triaged and yes they were low acuity walk in/urgent care stuff. This happend on the evening shifts in the ED when there was only one attending so the ED residents presented to him, while us rotaters presented to the PA. Like I said just rotating threw as a TY, didn't want to make a stink about it on my way to my specialty just another hoop to jump threw.

That's true but I don't really advocate residents presenting to PAs. I do think that PAs can teach residents about technical skills. That goes to the "no role in education" comments some had made in this thread.

I agree with that, the PAs tough me all kinds of technical skills, but presenting to them and them barking orders at me like they were my attending didn't sit right with me.

 

[mig26x]

That's true but I don't really advocate residents presenting to PAs. I do think that PAs can teach residents about technical skills. That goes to the "no role in education" comments some had made in this thread.

My question to you though was about how you would "draw the line" at being taught by a midlevel. Would you not rank any program that has midlevels teaching? How about any program that uses midlevels on the off chance you might find yourself being taught by one at some point? If you found yourself in that position how would you address it with your PD? That might get sticky and you may need to decide just how much not being taught by a midlevel means compared to all the other good stuff a program may have to offer.

hi, regarding your questions:

1- how would I draw the line at being taught by a midlevel? if my ED attending (Im an IM resident but did one month ED rotation) told me to precept with a PA in my hospital which they also have to precept with the attending I would bring the point "they also present to an attending therefore I dont feel this is the best route" if the PA in the hosp work solo I would have told my attending that "I'm on residency training and therefore I have to present to an attending to verify an adequate care management".

2- I would not rank any program where I would have to present/precept any case with a PA and she/he has the final ok. I have talked to cardiology PA who then present to the cardiology attending and they are the one's who give the ok on plan/management. I don't have any problem on talking to PA about case and plan if its going to be run through an attending.

3- I'm in a program where PA have to precept with attendings etc etc. I wouldn't have any problem talking to my PD about me presenting and precepting with PA's, that's not their role and therefore is not the correct pathway, not for me for my education or for the patient best care management.

Again, i dont have any problem talking and presenting (not precepting) with a PA if I know an attending has the final OK on plan etc.

 

[Taurus]

nope! Im mig26x also known as mig24x two years before opening this account!! LOL.

It does make you wonder who the reincarnation of Mac is.

 

[Taurus]

I always assumed it was you.

I like to think of myself as being more even-handed than he was. But the nurses may beg to differ.

 

[oompaloompa]

I'm torn regarding the role of NPs at my training institution. On the one hand they can(and do) make my life as a resident easier by taking on some of the stable chronic kids that don't offer much in the way of education. Often they take care of annoying secretarial crap I don't want to touch.

However, the problem of the NP (at least at my institution) is that they don't have to work nights, weekends, holidays, or basically whenever they don't feel like it. Then it becomes your problem. I also take issue with someone who takes twice as long to do half as much work, for double the pay. The slowest intern can see 8 patients in a morning, but the NP will take all day to see 4 and be visibly flustered.

I don't forsee a time in the near future when the residents at my program would be replaced by NPs, it would take a veritable army. An army that would demand high pay, reasonable hours, and lots of time off.

Remember the lesson of Houston's Methodist program. They decided to sever ties with Baylor and lost all their resident support. They hired 70 NPs to cover the work of the 30 lost residents - which as any resident could have told you, wasn't nearly enough. Also, the financial loss was huge given the high salaries they now had to pay to twice the people plus the loss of federal funding and cheap slave labor hours. It was a disaster, so predictably the hospital scrambled to get an association with Cornell - who now sends their residents down from New York.

The lesson was clear from this scenario, NPs and residents are NOT equivalent, much less NPs and board-certified physicians.

 

[flumazenil]

.

 

[flumazenil]

I halfway wonder if you're at a hospital I rotated through in the North East. There were two NPs managing the "stable" floor patients. Each resident service carried between 8-25 patients on any given day, the NPs were "overwhelmed" when they hit 6. They were always the first people to sign out in the afternoon, and always left more work to do than any other team. At least 2-3 times per week patients were transfered from the NP to the resident service due to declining clinical status, usually as a consequence of missing the little, simple things.

I have always been amazed that hospital-based physicians would hire NPs period. Nothing in their training suggests that they are capable of functioning in an inpatient environment, much less on a surgical service. Yet I keep seeing and hearing about them taking care of patients on the wards. It's bizarre.

i dont agree with it either..but cheap labor can change many minds....

 

[mig26x]

It does make you wonder who the reincarnation of Mac is.

dont worry, i been mig24x or mig26x all this time.

 

[Trifling Jester]

2- I would not rank any program where I would have to present/precept any case with a PA and she/he has the final ok. I have talked to cardiology PA who then present to the cardiology attending and they are the one's who give the ok on plan/management. I don't have any problem on talking to PA about case and plan if its going to be run through an attending.

I think that's outrageous. Residents should be presenting patients to the attending, not the PA.

-The Trifling Jester

 

[Taurus]

I would not rank any program where I would have to present/precept any case with a PA and she/he has the final ok.

If it is well known by prospective residents (via boards like SDN) that certain programs make residents regularly present to midlevels and are precepted by them, those programs will have a very hard time matching top candidates. This is a huge red flag for the program, akin to being on probation.

 

[deleted6669]

If it is well known by prospective residents (via boards like SDN) that certain programs make residents regularly present to midlevels and are precepted by them, those programs will have a very hard time matching top candidates. This is a huge red flag for the program, akin to being on probation.

that would only be an issue if the top programs weren't doing this(and they are) and others were.
many top em residencies( and MANY in family medicine) use pa's/np's/cnm's to teach residents during their training....

 

[deleted6669]

Keeping in mind the distinction drawn above between instruction in certain areas (procedures, limited specialty areas) and precepting/presentation, are you really saying that many top EM and FP programs have mid-levels who instruct residents on appropriate management of patients?

I would say many/most do specific procedures instruction and some( don't know specific % but fp>em) have midlevels precepting residents directly on specialty rotations. every job I have ever had in em has had me directly precepting fp residents doing rotations in my dept with both procedures AND pt presentations...maybe this is more of a west coast thing but it isn't that uncommon. where I work the residents are assigned to a shift not a preceptor so some days they present to md's and some days to pa's. at only 1 job have I been the preceptor of record and actually written the evals...at my current job the evals are written by the dept chief who often has never met the resident but writes a summary eval based on input from the clinicians(both md and pa) who have.

 

[Taurus]

I would say many/most do specific procedures instruction and some( don't know specific % but fp>em) have midlevels precepting residents directly on specialty rotations. every job I have ever had in em has had me directly precepting fp residents doing rotations in my dept with both procedures AND pt presentations...maybe this is more of a west coast thing but it isn't that uncommon. where I work the residents are assigned to a shift not a preceptor so some days they present to md's and some days to pa's. at only 1 job have I been the preceptor of record and actually written the evals...at my current job the evals are written by the dept chief who often has never met the resident but writes a summary eval based on input from the clinicians(both md and pa) who have.

Working with midlevels for a month as an introduction to the specialty is fine. However, a line needs to be drawn so that midlevels aren't precepting residents for significant portions of their specialty. It's fine for EM PA's to precept FM residents during their 1 month EM rotation. It's wrong for EM PA's to precept PGYII-IV EM residents, probably even PGYI. If that is the case, then most top applicants would stay away from such a program. We, as prospective applicants, would hear it during our candid conversations with current residents during interview day. We came to medical school to be trained by physicians. We need them to pass on their knowledge and approach to problems to the next generation.

It's not a knock against emedpa. I'm sure he's a fine PA and knows his stuff.

What if the precepting midlevel isn't so skilled? What if the midlevel is a DNP who earned it online? I don't want somebody like that precepting me.

 

[deleted6669]

Working with midlevels for a month as an introduction to the specialty is fine. However, a line needs to be drawn so that midlevels aren't precepting residents for significant portions of their specialty. It's fine for EM PA's to precept FM residents during their 1 month EM rotation. It's wrong for EM PA's to precept PGYII-IV EM residents, probably even PGYI.

I have never precepted em residents on things other than procedures.
our fp residents do 1 month/yr in em and we precept them all 3 yrs.
by the time they are done most of them have spent less time in the ed than a pa who expressed an interest in em during their pa program; for instance I did 22 weeks of em( 12 community/5 peds em/5 inner city em) + 5 weeks trauma surgery out of 54 weeks of total rotations.

 

[Trifling Jester]

that would only be an issue if the top programs weren't doing this(and they are) and others were.
many top em residencies( and MANY in family medicine) use pa's/np's/cnm's to teach residents during their training....

What top programs are these, so everyone can know to stay away from them?

-The Trifling Jester

 

[deleted6669]

What top programs are these, so everyone can know to stay away from them?

-The Trifling Jester

if you avoid all the ones listed here you will never need to work with a midlevel:

http://www.ama-assn.org/ama/pub/category/2997.html

 

[mig26x]

if you avoid all the ones listed here you will never need to work with a midlevel:

http://www.ama-assn.org/ama/pub/category/2997.html

I think you are taking all this the wrong way. One thing is to work with mid-levels (which I think everyone has done before) and another is to precept to a mid-level while in residency no matter your PGY year instead of an attending.

 

[Trifling Jester]

if you avoid all the ones listed here you will never need to work with a midlevel:

http://www.ama-assn.org/ama/pub/category/2997.html

I am asking you which programs you've observed where residents present patients to PAs instead of presenting them to attendings. You've linked to the FREIDA website, which lists all residency programs.

-The Trifling Jester

 

[dragonfly99]

siempre (the OP):
On rereading your post, I think the main issue may be a lack of educational opportunities that you are experiencing. IMHO no matter what hospital or residency you are in, there is bound to be some conflict between docs, nurses, PA's, NP's, other hospital staff...whomever. My advice is not to get into it with ANY RN, NP, etc. as a resident you will NOT win. The hospital staff are important to the hospital and residents, although important, are NOT in a power position and you ain't leaving for another residency, so better to make the best of your situation and not make any enemies.

The "stealing" of procedures interestes me. Is it that the NP's/PA's are just trying to get the work done ASAP and aren't really thinking about the fact that you guys are getting deprived of procedures? I know some people are just kind of hateful and/or possessive about stuff, but it might be more of an innocent thing where the PA/NP is just trying to get the work done and either doesn't realize you want to do the procedure, or doesn't feel like waiting for you to have time to do it. Either way, it seems like something to take up with the chief resident(s) and/or your PD...but hopefully in a nonconfrontational way, and with other residents if you can. This way you seem less like a complainer or someone who has problems with other people, and more like somebody who just wants to learn new skills.

p.s. I don't think there's anything wrong with an NP or PA teaching me certain thing, particular specialized skills (or an RN, etc.). I had an NP show me how to drain fluid from a chest tube apparatus/tubing with an 18 guage needle...all the surgeons were in the OR. I'm sure many PA/NP's in the ER know all about putting on splints. Many RN's are great at drawing blood and putting in IV's, etc. I do think that MD and DO's should keep up their skills (i.e. ER attending should still know how to do I and D's) so that they can teach also. I think in general it's preferable for MD/DO trainees to present cases to the MD/DO who is responsible for teaching them. IMHO it really shouldn't be the PA or NP's responsibility to precept trainees in general, but I'm sure there are exceptions to every rule.

 

[Law2Doc]

I think your question is a valid one. A resident physician who is training to be board certified in a specialty deserves to learn from someone who is at the level they are striving for. Pawning off precepting responsibilities on PAs and NPs is just lazy and wrong.

I think there are a lot of interesting discussion concepts badly intertwined in this thread. In terms of teaching, I think it's silly to worry about a person's station. If someone knows more than you, then they can be your teacher. So a PA or NP with years of experience ought to be able to teach a resident fresh out of med school. The student will absolutely surpass the teacher in this situation given the ultimate position the resident will achieve, but until that happens, there isn't a good reason a mid-level ancillary professional couldn't teach a higher level professional in training. Heck, an attending can learn from an intern if the intern knows more about a certain topic or procedure. It's substance over form.

As for NP/PAs "stealing" procedures, this happens a lot at hospitals where you have to do a number of supervised procedures before you are "signed off" to do them. In a hospital with a residency program, I think the resident, the person the government is effectively paying the hospital to train, needs to get first crack at it.

Finally, the basic concept of NPs/PAs acting autonomously are being marketed to patients as the equivalent of physicians represents a huge misstep by the medical profession. Physicians need to organize and lobby to set limits as to what ancillary professions should be allowed to do and not do. There is huge encroachment going on, there are ancillary professionals acting as if they are physicians, some even holding themselves out as doctors. In law, similar encroachments have been attempted by paralegals, realtors, accountants. In each case lawyers fought tooth and nail and very specific legislative boundaries as to what constitutes "the unauthorized practice of law" now exist, into which ancillary professionals dare not treat or risk huge lawsuits and penalties. Physicians could do likewise, but thus far are poorly organized and their organizations even more poorly funded. This needs to be fixed, or you will see gradual erosion and blurring of physician roles, additional encroachment, and more and more non-med school trained individuals calling themselves "doctor". The high costs of healthcare make these ancillary professionals an easy fix in the government's eyes, so doctors actually need to move fast to shut this down.

 

[Taurus]

Finally, the basic concept of NPs/PAs acting autonomously are being marketed to patients as the equivalent of physicians represents a huge misstep by the medical profession. Physicians need to organize and lobby to set limits as to what ancillary professions should be allowed to do and not do. There is huge encroachment going on, there are ancillary professionals acting as if they are physicians, some even holding themselves out as doctors. In law, similar encroachments have been attempted by paralegals, realtors, accountants. In each case lawyers fought tooth and nail and very specific legislative boundaries as to what constitutes "the unauthorized practice of law" now exist, into which ancillary professionals dare not treat or risk huge lawsuits and penalties. Physicians could do likewise, but thus far are poorly organized and their organizations even more poorly funded. This needs to be fixed, or you will see gradual erosion and blurring of physician roles, additional encroachment, and more and more non-med school trained individuals calling themselves "doctor". The high costs of healthcare make these ancillary professionals an easy fix in the government's eyes, so doctors actually need to move fast to shut this down.

Amen, brother. The DNP's, PharmD's, DPT's, chiroprictors, optometrists, podiatrists, psychologists all want to increase their scope and do what has traditionally been medicine. There is even talk of a DPA for PA's and making them equivalent to board certified physicians in certain specialties like FM, EM.

All specialties need to learn from the surgeons. There is a very clear boundary between surgeons and everyone else. Nobody in this country can do surgery if not a surgeon. You can't say that about diagnose and treatment anymore. Nearly every group who wants prescription rights gets it now. These groups think that if they create a "doctorate" for themselves that it gives them a blank check to do medicine. Physicians need to put an end to this ridiculousness. We need to be like the lawyers. Fiercely defending our profession. Pummeling our adversaries so hard that they run away with their tails between their legs.

 

[deleted6669]

In terms of teaching, I think it's silly to worry about a person's station. If someone knows more than you, then they can be your teacher. So a PA or NP with years of experience ought to be able to teach a resident fresh out of med school. The student will absolutely surpass the teacher in this situation given the ultimate position the resident will achieve, but until that happens, there isn't a good reason a mid-level ancillary professional couldn't teach a higher level professional in training. Heck, an attending can learn from an intern if the intern knows more about a certain topic or procedure. It's substance over form.

thanks-at least someone gets it......I would hope that after 22 yrs working in em at level 1-5 trauma ctrs and holding every merit badge cert there is in em I would know more em than the vast majority of interns and might be able to teach them something and precept their cases...those 100,000+ pts I have seen over the yrs have to count for something....

 

[deleted6669]

There is even talk of a DPA for PA's and making them equivalent to board certified physicians in certain specialties like FM, EM.

as you well know a dpa still needs a supervising physician and is in no way equivalent to an md/do. the degree( it only exists in 1 place and only for active duty military) was created mostly to allow pa's to get rank promotions within the armed forces that require a doctorate level degree....

 

[Long Dong]

Amen, brother. The DNP's, PharmD's, DPT's, optometrists, podiatrists, psychologists all want to increase their scope and do what has traditionally been medicine. There is even talk of a DPA for PA's and making them equivalent to board certified physicians in certain specialties like FM, EM.

All specialties need to learn from the surgeons. There is a very clear boundary between surgeons and everyone else. Nobody in this country can do surgery if not a surgeon. You can't say that about diagnose and treatment anymore. Nearly every group who wants prescription rights gets it now. These groups think that if they create a "doctorate" for themselves that it gives them a blank check to do medicine. Physicians need to put an end to this ridiculousness. We need to be like the lawyers. Fiercely defending our profession. Pummeling our adversaries so hard that they run away with their tales between their legs.

I double that amen, just docs can't get it together like lawyers. On the show ER it was said that "lawyers are half as smart as doctors but twice as cunning." Docs just can't get it together to protect their own interest. I remember reading a thread about how docs tried to shut out chiropractors but that didn't work.

 

[Law2Doc]

I double that amen, just docs can't get it together like lawyers. On the show ER it was said that "lawyers are half as smart as doctors but twice as cunning." Docs just can't get it together to protect their own interest. I remember reading a thread about how docs tried to shut out chiropractors but that didn't work.

The fight against chiropractors is the big reason physicians are gun-shy about going to court, I think. This fight spanned many years, at many appellate levels, with physicians not really putting good evidence to the courts beyond the blanket position that chiropractors were "quacks" and shouldn't be allowed to call themselves "doctor". Should have been approached first at the lobbyist/legislative level, and then more smartly advocated in court. But yeah, the docs had their &#sses handed to them and haven't pushed the practice of medicine issue much since then. They seem to lack the stomach for fighting that lawyers have. Which is why all the smaller kids in the playground (PA, NP, CRNA) are having an easy time taking away their toys. This can be fixed, but requires a big adjustment in attitude, an organization (the AMA?) to step it up and take the lead, and a willingness to pony up some dues money for the effort.